Healthcare Provider Details

I. General information

NPI: 1790465698
Provider Name (Legal Business Name): THE VICE PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 E TOMPKINS AVE STE 101
LAS VEGAS NV
89121-5466
US

IV. Provider business mailing address

9160 MOHAWK ST
LAS VEGAS NV
89139-7508
US

V. Phone/Fax

Practice location:
  • Phone: 725-724-2005
  • Fax: 877-418-8013
Mailing address:
  • Phone: 702-931-1434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SUSIE MIRELES
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 702-630-5740